Diagnostic accuracy of contrast enhanced computed tomography (CECT) in detection of necrosis in acute pancreatitis by taking surgical findings as gold standard.

OBJECTIVE: To determine the diagnostic accuracy of contrast-enhanced computed tomography in the detection of necrosis in acute pancreatitis by taking surgical findings as the gold standard. METHODS: The descriptive cross-sectional study was conducted at Radiology and Surgery departments of the Jinnah Postgraduate Medical Centre, Karachi, from January 1 to June 30, 2016, and comprised patients of either gender having severe clinical pancreatitis with symptoms lasting >72 hours without showing improvement. Computed tomography scan was performed with slice thickness of 3mm. Multiple detector scan of abdomen with contrast was done. Data was analysed using SPSS 19. RESULTS: Of the 191 patients, 97 (50.8%) were female, and 129 (67.50%) were aged >40 years, with an overall mean age of 39.65±11.67 years. Mean duration of the symptoms was 85.61±6.41 hours. Contrast-enhanced computed tomography scan's sensitivity was 71.4%, specificity 87%, positive predictive value 83.33%, negative predictive value 76.99% and over all diagnostic accuracy was 79.5%. CONCLUSIONS: The diagnostic accuracy of contrast-enhanced computed tomography was found to be high in detecting necrosis in acute pancreatitis cases.

Surgical Outcome of Decompression and Fixation of Degenerative Lumbosacral Spondylolisthesis Surgery in Pakistani Population.

Background Spondylolisthesis is characterized by the slipping of one vertebra, compared with the underlying one, due to structural and degenerative changes. Its origin is multifactorial which includes disc degeneration, facet joint anatomic orientation, iliolumbar configuration, and ligament hyperlaxity. The most common operative treatment is decompression and may require an individualized surgical plan. However, only decompression may progress the slippage which can result in pain or recurrence of neurological complaints. Therefore, lumbar fusion and fixation are considered appropriate to stabilise the spine and prevent delayed deterioration. The aim of our study was to find out the outcome of posterior decompression, with reduction and fixation of lumbosacral spondylolisthesis by Oswestry Disability Index (ODI) to improve further our results. Methods This study was conducted from July 2013 to February 2017 including 94 patients with lumbosacral spondylolisthesis. The Meyerding classification was used to grade the extent of vertebral slippage. The assessment was done using the ODI. Results There were 50 (53.19%) males and 54 (46.80%) females with a mean age of 44 years ± 10.49 SD. Backache was present in all patients and claudication in 85 (90.42%) patients. There were 10 (10.63%) patients with spondylolisthesis at L3-L4, 36 (38.29%) at L5-S1 and 48 patients (51.06%) at L4-L5 level. In 48 patients with L4-L5 level, 38 (79.16%) were in grade II while six (12.5%) were in grade III. According to the preoperative ODI score, 38 patients were placed in moderate disability, 42 patients were severely disabled while four patients were disabled. Good outcome was achieved in a total of 79 (84.04%) patients. In 40 (42.55%) patients, with complete reduction, the good outcome achieved in 35 (83.33%) while in 22 (23.40%) patients there was no reduction and a good outcome was achieved in 17 (77.27%) patients. In 38 (40.42%) patients with moderate disability, 32 (84.04%) patients had a good outcome. Post-operative cerebrospinal fluid (CSF) leak occurred in five (5.31%) and wound infection in seven (7.44%) patients while there was no mortality. Conclusion Reduction with decompression can have a good outcome in spondylolisthesis, and ODI should be used as a predictor of outcome. It also shows that proper decompression is required and not a complete reduction.

Intracranial Epidermoid Lesions: our Experience of 38 Cases.

BACKGROUND: The clinical outcome following surgical resection of intracranial epidermoid lesions is not well documented. We describe a case series evaluating the clinical presentation and outcome following surgery in patients diagnosed with these lesions. MATERIALS AND METHODS: A retrospective study conducted over a 4-year period. RESULTS: A total 38 patients who underwent surgery for intracranial epidermoid lesions were identified. Of these, 20 were supertentorial and 18 were infratentorial lesions. 33 patients presented with headache. 10 patients with supratentorial lesions presented with seizures. Patients with suprasellar epidermoid lesions presented with headache and visual problems. 14 of the 18 patients with cerebellopontine angle lesions presented with symptoms of trigeminal neuralgia. Post-operatively, 3 patients with cerebellopontine angle tumors developed facial weakness which was transient in 2 patients but permanent in 1 patient. Visual impairment in patients with suprasellar epidermoid lesions improved post-operatively. Hormonal replacement therapy was required in 2 patients. Recovery of 4 patients was complicated by Cerebrospinal fluid (CSF) leak while meningitis developed in 2 patients. One patient operated for cerebellopontine angle epidermoid died post operatively. CONCLUSIONS: Epidermoid lesions can develop anywhere in the cranial cavity. Like other space occupying lesions they often present with symptoms of raised ICP and with specific neurological deficits depending on location of the tumour. Surgical outcome is excellent with low complication rates.

Posterior occipito cervical decompression with fixation and fusion in Cranio vertebral junction compression.

OBJECTIVE: To find out the clinical outcome of posterior decompression with occipitocervical fixation and fusion in patients with Craniovertebral junction instability. METHODS: Eighty consecutive patients of cranio vertebral junction (CVJ) compression were treated in the department of neurosurgery, Jinnah Postgraduate Medical Centre (JPMC), Karachi over a period of 05 years from 1st January 2012 till 31st August 2016. All patients underwent posterior decompression with occipitocervical fusion (OCF) and fixation. The clinical outcome was assessed by Japanese Orthopedic Association (JOA) score and grading. RESULTS: Out of 80 patients with CVJ instability, 64 (80%) were due to non traumatic causes, while 16 (20%) were secondary to trauma. All 80 patients(100%) showed post operative relief in pain. Sixty four (80%) patients showed improvement in power post operatively while six (7.5%) had no change, four (5%) showed deterioration and six (7.5%) patients expired. Sixty four (80%) patients had improvement of the JOA scores at last follow-up. According to etiology, the JOA score for patients with trauma improved in 12(75%) patients and 52(81.25%) for non traumatic causes while six patients (7.5%) expired. Fusion was achieved in 64 (80%) patients at last follow-up. CONCLUSION: Posterior decompression with occipitocervical fusion and fixation is safe and can be recommended in cases of CVJ compression.

Postoperative Functional Outcome of Intradural Extramedullary Spinal Tumors Through Posterior Approach.

OBJECTIVE: To determine functional outcome of intradural extramedullary spinal tumors in patients undergoing excision through the posterior approach alone. STUDY DESIGN: Interventional study. PLACE AND DURATION OF STUDY: Neurosurgery Department, JPMC, Karachi, from March 2011 to February 2014. METHODOLOGY: Patients with intradural extramedullary spinal tumors (IDEM), confirmed on MRI, were admitted through Outpatient Department. Those with bleeding disorders, diabetes mellitus, previously operated and with no histopathological evidence of tumor on biopsy, were excluded. Clinical signs, symptoms and location of the tumor were noted. These patients then underwent laminectomy and excision of tumor through the posterior approach, regardless of the location or type of tumor. Transpedicular screw was placed where the tumor was so large, as to cause posterior instability. The functional outcome was evaluated by assessment of Medical Research Council (MRC) Scale for Muscle Strength preoperatively and at 6 months follow-up postoperatively. Good outcome was labelled when there was improvement from previous grade before surgery to higher grade, as assessed by muscle strength on follow-up at 6 months after surgery. RESULTS: The mean age of the 38 patients was 42.6 ±10 years. Majority were females (68.42%). Meningioma was the commonest tumor (63.15%). The commonest location was thoracic spine (73.68%). Backache was present in all (100%) patients, motor weakness in 30 (78.92%) patients, sensory disturbance in 5 (13.5%) patients, sphincter disturbance in 7 (18.42%) patients, and shortness of breath in 1 (2.63%) patient. Preoperatively, there were 10 patients (26.31%) in grade 3, 9 (23.68%) patients in grade 0, 8 (21.05%) in grade 1, 7 (18.42%) patients in grade 2. After 6 postoperative months, there were 23 (60.52%) patients in grade 5, 5 (13.15%) patients in grade 3, 5 (13.15%) patients in grade 2 and 2 (5.26%) patients in grade 1. Postoperative complications were CSF leak, respiratory distress, wound infection and incontinence. CONCLUSION: Functional outcome of intradural extramedullary spinal tumors was found to be good.

Zuckerkandl Tubercle: An Important Landmark in Thyroid Surgery.

OBJECTIVE: To find out the frequency of Zuckerkandl Tubercle (ZT) and the position of recurrent laryngeal nerve with reference to ZK. STUDY DESIGN: Cross-sectional observational study. PLACE AND DURATION OF STUDY: Surgical Ward-3, Jinnah Postgraduate Medical Centre (JPMC), Karachi, from June 2010 to August 2011. METHODOLOGY: Patients having goiter, aged between 12 - 60 years were admitted through OPD and operated after informed written consent. After admission, they underwent surgery. ZT and recurrent laryngeal nerve position i.e. whether medial, lateral or posterior to ZT was identified during surgery. Data was collected on pre-designed proforma and analysed on SPSS version 15 for descriptive statistics. RESULTS: Out of the 84 patients ZT was found in 52 (61.90%) patients. Nineteen patients had grade-I (less than 0.5 cm), 22 (42.3%) had grade-II (0.5 - 1 cm) and 11 (21.1%) had grade-III (more than 1 cm) ZT. During surgery, 33 (63.4%) patients had recurrent laryngeal nerve medial to ZT, 15 (28.8%) patients had lateral and in 4 (7.6%) patients recurrent laryngeal nerve was engraved posteriorly. CONCLUSION: Zuckerkandl tubercle was found in about 62% cases; recurrent laryngeal nerve was located pre-dominantly medial to ZT.

Dandy-Walker Malformation: A Clinical and Surgical Outcome Analysis.

OBJECTIVE: To determine the clinical presentations, complications and mortality in patients with Dandy-Walker Malformation (DWM) after surgery i.e., shunt with y-connector. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Neurosurgery Ward, JPMC, Karachi, from January 2009 to December 2013. METHODOLOGY: Cases of DWM, with associated hydrocephalus, further confirmed on CT scan of brain, were admitted through OPD. Those who were previously operated, those with other associated co-morbid or anomalies were excluded from this study. Combined drainage of the ventricular system and posterior fossa cyst, via dual shunt i.e. cystoperitoneal and ventriculoperitoneal shunt with y-connector was performed in all patients. Complications and mortality after surgical intervention in these patients were noted upto one month after surgery. The data analysis for descriptive statistics was done on SPSS version 20. RESULTS: In this study of 70 patients, majority of the patients were female aged between 1 - 2 years. Hydrocephalus was the predominant symptom as being present in all patients, followed by cerebellar signs in 60 (86%), and other in 5 (7.14%) patients. Complications of surgery were infection and shunt fracture dislocation in 7 (10%) each, malpositioning and shunt blockage in 6 (8.5%) each within one month of surgery, intracranial haemorrhage in 5 (7.14%) patients. Only one patient (1.42%) expired after surgical intervention. CONCLUSION: In DWM, the commonest presentation is that of hydrocephalus. Shunt malfunction and infection are the commonest complication after shunting. Dual shunt with y-connector has the lowest mortality when compared with other methods for treatment of shunt with y-connector.

Posterior fossa decompression with duraplasty in Chiari-1 malformations.

OBJECTIVE: To evaluate the symptomatic outcome after PFD (Posterior Fossa Decompression) with duraplasty in Chiari-1 malformations. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Department of Neurosurgery, JPMC, Karachi, from July 2008 to September 2012. METHODOLOGY: This included 21 patients of Chiari 1 malformations admitted in department through OPD with clinical features of headache, neck pain, numbness, neurological deficit, and syringomyelia. Diagnosis was confirmed by MRI. PFD followed by C1 laminectomy with duraplasty was done in all cases and symptomatic outcome was assessed in follow-up clinic. RESULTS: Among 21 patients, 13 were females and 8 were males. Age ranged from 18 to 40 years. All the patients had neck pain and numbness in hands. Only 3 patients had weakness of all four limbs and 12 with weakness of hands. Symptoms evolved over a mean of 12 months. Syringomyelia was present in all cases. All patients underwent posterior fossa decompression with duraplasty with an additional C1 laminectomy and in 2 cases C2 laminectomy was done. Syringo-subarachnoid shunt was placed in one patient and ventriculo-peritoneal shunt was placed in 2 patients. Pain was relieved in all cases. Weakness was improved in all cases and numbness was improved in 19 cases. Syringomyelia was improved in all cases. Postoperative complications included CSF leak in 2 patients and wound infection in one patient. However, there was no mortality. CONCLUSION: Posterior fossa decompression with duraplasty is the best treatment option for Chiari-1 malformations because of symptomatic improvement and less chances of complications.

Carcinoma thyroid in multi and uninodular goiter.

OBJECTIVE: To determine the frequency and profile of carcinoma in multi-nodular goiter and solitary thyroid nodule. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Surgical Unit-I, Ward-3 of Jinnah Postgraduate Medical Centre, Karachi, from January 1999 to January 2009. METHODOLOGY: Cases with solitary thyroid nodules and multi-nodular goiter were included. Patients under 12 years of age, cystic benign lesion in solitary thyroid nodules or those multi-nodular goiters which were not causing pressure symptoms, cosmetic problems or sign of malignancy were excluded. In solitary thyroid nodule, hemithyroidectomy was done and if histopathology examination revealed carcinoma thyroid then completion thyroidectomy was done. In multi-nodular goiter sub-total thyroidectomy done. Results were described as frequency percentages and mean. RESULTS: Out of 397 patients of multi-nodular goiter only one patient was found to be papillary carcinoma (0.25%). In 220 patients of solitary thyroid nodules, 93 patients were diagnosed as carcinoma of thyroid (42.27%). Others diagnosed in solitary thyroid nodule were thyroid adenoma, colloid goiter, thyroiditis and multi-nodular goiter. The frequency of papillary carcinoma in 65.95% occuring females of 12-30 years of age and being multifocal in 6.45%, follicular carcinoma in 23.40%, medullary carcinoma in 7.44%, anaplastic carcinoma in 2.12% and lymphoma in 1.01%. Female were predominantly involved and papillary carcinoma was common in 12-30 years of age (71.63%) and follicular was common in 30-40 years of age (68.18%). 6.45% of papillary carcinoma was found to be multifocal in nature. CONCLUSION: Frequency of carcinoma of thyroid is very high in solitary thyroid nodule (42.27%), but markedly low in multinodular goiter. Papillary carcinoma is the most common variety, most of in younger female.

Late presentation of a patient with an anorectal malformation (ARM).

Vestibular fistula represents the most common type of anorectal defect seen in girls with anorectal malformation. Adult presentation of this malformation is rare. The following is a case of adult presentation of anorectal malformation with a vestibular fistula in a 23 years old female, who came because of cosmetic and fertility concerns before her marriage. The patient complained of having an anorectal malformation since birth and passage of fecal matter through the fistula. The patient was continent for feces, but had leakage of flatus. She had no other associated anomaly. The patient subsequently underwent a surgical procedure where anal transposition was done with an intact skin bridge. Post-operatively, these developed an anal stenosis which was successfully treated through anoplasty, and the patient is now continent both for feces and flatus for the last 6 months.

A case of pseudotumorous form of ascaris.

A 35-year-old woman presented with lower abdominal pain and amenorrhoea. CT showed a thick walled lobulated mass with Ascaris adjacent to caecum along with the presence of a left ovarian mass. The peroperative findings were a tubular mass with central tunneling containing an Ascaris lumbricoides. Left ovary showed a haemorrhagic cyst. Biopsy of the mass showed acute on chronic granulomatous inflammation and the worm was found to be female. This was a rare case of Ascaris lumbricoides presenting as a pseudotumorous mass.

Outcome of stapled haemorrhoidectomy versus Milligan Morgan's haemorrhoidectomy.

OBJECTIVE: To compare the postoperative outcome of stapled haemorrhoidectomy and conventional Milligan Morgan's open haemorrhoidectomy. STUDY DESIGN: Comparative study. PLACE AND DURATION OF STUDY: Surgical Unit 1, Ward-3, Department of Surgery, Jinnah Postgraduate Medical Centre, Karachi, from March to September 2006. METHODOLOGY: Sixty patients of late 2nd, 3rd and 4th degree haemorrhoids were selected for admission from the outpatient department after taking informed consent. Patients with concomitant anal disease (e.g. fissure, abscess, fistula, ano-rectal cancer etc.) were excluded. Two groups of thirty each were made, one for Milligan-Morgan open haemorrhoidectomy and another for stapled haemorrhoidectomy, in which excision of a ring of mucosa proximal to the haemorrhoid(s) was done thus, interrupting the blood supply but maintaining continuity of the rectal mucosa. The operative time was measured in minutes. Postoperative pain was assessed through VAS. Bleeding was measured as no, mild, profuse. Other post-operative complications during hospital stay like urinary retention, anal stenosis etc. were noted. Student t-test, chi-square test and repeated measured analysis of variance were applied to compare the variables. RESULTS: The mean age was 40.7+/-11.6 years. A majority (53.3%) of patients (combined % in both groups) had third degree haemorrhoid. The mean length of operative time was found statistically insignificant between open and stapled groups (19.6+/-5.9 vs. 22.4+/-7.2 minutes, p=0.974). However, the mean length of postoperative hospital stay was significantly less in the stapled than open haemorrhoidectomy group (3.37+/-2.2 vs. 2.03+/-0.81 days, p=0.003. Mean postoperative pain (observed by VAS) in the stapled group was significantly less than the open haemorrhoidectomy group (4.43+/-1.25 vs. 7.37+/-0.72). The proportion of postoperative bleeding, infection, anal tag, urinary retention, tenderness on digital rectal examination and wound discharge was higher in open than stapled haemorrhoidectomy group, but statistically insignificant (p < 0.05). CONCLUSION: There was a significant difference between Milligan Morgan's and stapled haemorrhoidectomy for postoperative pain and hospital stay. However the mean length of operative time was insignificantly different.

Tubercular fistula-in-ano.

OBJECTIVE: To determine the frequency of tuberculosis in recurrent fistula-in-ano. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: This study was conducted in Surgical Ward-3, Jinnah Postgraduate Medical Centre, Karachi, Pakistan, from 1998 to 2007. PATIENTS AND METHODS: The study included 100 cases of recurrent fistula-in-ano not responding to conventional surgery. Patients with other co-morbidities such as diabetes mellitus, bleeding disorders or with the evidence of pulmonary, abdominal or intestinal tuberculosis were excluded from this study. Fistulogram was performed in all patients. All the patients were subjected to fistulectomy followed by histopathology of the resected specimen. Thereafter, confirmation of the disease, anti-tuberculous treatment was immediately started and response to treatment was observed after 6 months. RESULTS: Out of the 100 studied patients, 11 cases had biopsy proven tuberculosis in the fistula. All the patients were male. The fistulae were low type, single and usually located posteriorly (n=9) with everted margins. Ten were located within 3 cm of anus. Fistulogram revealed single internal opening. Comparative statistics of tuberculous fistula-in-ano with fistulas due to specific inflammation revealed no major differences. The diagnosed patients of tubercular fistulae-in-ano were observed for at least 6 months after starting anti-tuberculous treatment. They all responded well to anti-tubercular treatment and the fistulae healed without any complication such as recurrence or anal stenosis within 6 months. CONCLUSION: Tuberculosis should be suspected in case of recurrent fistulae-in-ano, so as to avoid unusual delay in the treatment and miseries to the patient. Appropriate anti-tuberculous therapy leads to healing within 6 months.